Senior Eligibility Representative- Accredo- Encore

📋 Description

• • As a Senior Eligibility Representative within The Cigna Group's Accredo Encore Program, you will be instrumental in bridging the gap between patients, healthcare providers, payers, and the intricacies of specialty pharmacy operations. This unique role is specifically designed for retirees of The Cigna Group, offering a valuable opportunity to leverage your extensive experience and continue making a significant impact.
• • Your primary focus will be to bring clarity to complex insurance benefits, proactively identify and resolve drug coverage and eligibility issues that could impede patient access to life-changing therapies. By doing so, you will directly contribute to reducing turnaround times for critical treatments and ensuring patients receive the care they need without unnecessary delays.
• • You will act as a crucial liaison, fostering strong relationships and clear communication channels between internal teams and external partners, including insurance payers, healthcare providers, and pharmaceutical manufacturers. This collaborative approach is designed to minimize friction in the patient journey and optimize health outcomes.
• • A core responsibility involves independently resolving complex patient claims and eligibility challenges. This requires a deep and nuanced understanding of both medical and pharmacy benefits, enabling you to navigate intricate scenarios with confidence and precision.
• • You will meticulously ensure that all claims and referrals submitted adhere strictly to payer requirements. This involves accurately validating essential information such as billing codes, service dates, prior authorization details, and coverage criteria, thereby preventing claim rejections and ensuring timely reimbursement.
• • The role demands performing comprehensive medical and pharmacy benefit verifications. This process requires the application of payer-specific rules and the exercise of sound professional judgment to confirm that services rendered are eligible for reimbursement, safeguarding both the patient and the organization.
• • Clear, confident, and concise communication is paramount. You will be responsible for updating internal and external stakeholders on patient status, providing expert guidance on the next steps in the process, and managing expectations effectively.
• • You will be expected to handle escalated issues with the utmost professionalism and discretion. This involves applying a thorough understanding of company policies and payer guidelines, while also recognizing when to escalate complex situations to higher levels of management for resolution.
• • A key aspect of this senior role is to identify recurring trends and underlying root causes that impact patient access and overall operational efficiency. Your insights will be invaluable in contributing to continuous improvement initiatives aimed at enhancing our services and patient experience.
• • You will play a vital role in supporting the development and growth of your colleagues. By coaching and guiding less experienced team members with patience and clarity, you will help foster a culture of knowledge sharing and skill development within the team.
• • The dynamic nature of the healthcare and specialty pharmacy landscape requires adaptability. You will need to quickly adjust to changing priorities and evolving processes while consistently maintaining a high level of accuracy, empathy towards patients, and unwavering accountability for your work.
• • This position offers the unique advantage of being a remote work opportunity within the United States, providing flexibility and work-life balance. However, it requires a reliable internet connection through cable broadband or fiber optic service with minimum speeds of 10Mbps download and 5Mbps upload to ensure seamless connectivity and productivity.
• • By joining the Encore Program, you are not just taking on a role; you are re-engaging with a company where your past contributions are valued, and your future impact can be significant. You will be part of Evernorth Health Services, a division of The Cigna Group, dedicated to creating innovative solutions that improve health and increase vitality for millions.